Provider Demographics
NPI:1326313446
Name:KELLY, SUSAN JEAN (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEAN
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 125
Mailing Address - Street 2:326 8TH STREET
Mailing Address - City:HUGO
Mailing Address - State:CO
Mailing Address - Zip Code:80821
Mailing Address - Country:US
Mailing Address - Phone:719-743-2526
Mailing Address - Fax:
Practice Address - Street 1:326 8TH STREET
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:CO
Practice Address - Zip Code:80821
Practice Address - Country:US
Practice Address - Phone:719-743-2526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO63693163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1013048495OtherNPPES
COC30256Medicare PIN